Psychiatric emergencies encompass situations in which an individual cannot refrain from acting in a manner that is dangerous to himself or herself or to others. The patient may be aware of the danger his behavior poses (as with an overdose with the intent to die) or he may lack insight into the effects of his actions (as in the case of a manic patient who engages in reckless sexual behavior). Even if the patient perceives that his actions are dangerous, he may be bent on engaging in these behaviors despite the risks. (A patient with schizophrenia who follows command hallucinations to commit theft is an example). Because of their lack of insight and judgment, patients in psychiatric emergencies are often brought to the attention of medical professionals by people in the community, including friends, family, police officers, or even bystanders.

Astute psychiatrists may also recognize psychiatric emergencies during routine outpatient care. Patients may report their inability to remain safe, either spontaneously or as elicited by the psychiatrist. When an emergency is recognized, the clinician must:

• Perform a complete assessment of the concerning behavior

• Reduce risk by transferring the patient to an emergency department (ED) or to a psychiatric hospital as needed

• Provide or arrange for follow-up for continuity of care

Agitation is a common element in many psychiatric emergencies and poses unintentional danger both to self and to others. Intentional self-endangerment is often accompanied by suicidal ideation. This article will focus on these presentations.

Pre-crisis planning

The process of safe assessment and successful resolution of many psychiatric emergencies begins well before the patient arrives. The physical environment is an important consideration. Patient evaluation rooms can be constructed to allow escape from an agitated patient and to safely contain the dangerous individual. In addition, the waiting room can be arranged so that all areas are visible from the reception desk. This enables early intervention for patients who become agitated. Finally, the reception desk itself can be constructed to allow for easy communication while still being high and broad enough to prevent an agitated patient from jumping over the desk.1

Appropriate staff training is invaluable. Those who sit at the front desk should be trained to recognize the warning signs of agitation because they are best positioned to observe those in the waiting area. They should also know how to alert the appropriate clinician and other staff about a developing emergency. Given that patients may become agitated during an interview, it is equally important for clinicians to have a mechanism for communicating distress to staff (eg, use of a hotline or panic button).1,2

Staff members should be assigned clear roles in the case of an emergency. For example, some could direct other patients away from an agitated patient while others contact security or police. Running a drill of the situation, as other disciplines do in “mock codes,” helps cement these roles and can reveal any deficiencies before a true emergency develops. Such training may reduce the frequency of assaults in the workplace.

CHECKPOINTS

• The safe assessment and successful resolution of a psychiatric emergency begins well before the patient’s arrival and includes preparation of the physical environment and a well-trained staff.

• In determining whether a patient is dangerous, focus on factors that tend to elevate the patient’s risk of intentional or unintentional harm to self and others.

• If an empathetic response by the clinician is not enough to diffuse a dangerous patient, patient referral to the emergency departmentis essential.

Initial evaluation

The clinician has 2 essential responsibilities in a psychiatric emergency: to maintain the physical safety of everyone involved and to assess the patient’s mental status for appropriate triage of subsequent care.

The appropriate action to maintain the safety of staff and other patients varies with the situation. A severely depressed or quietly delirious patient can be directed to a private room for further evaluation and management. On the other hand, a psychotic or otherwise agitated patient is unpredictable and potentially dangerous to others if cornered.

Initial assessment should focus on factors that elevate the patient’s risk of intentional or unintentional danger. In addition to assertions of suicidal or homicidal ideation, notable risk factors for imminent danger include evidence of intoxication, expressions of hopelessness, irritable affect, thought disorganization, disheveled appearance, and psychomotor agitation.